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A Brief History of Palliative Care

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Title: A Brief History of Palliative Care


1
A Brief History of Palliative Care
  • David L. Sharp, M.D.
  • Grand Rapids Medical Education Partners
  • Hospice of Michigan Grand Rapids

2
David L. Sharp, M.D. brief bio
  • B.S./M.D. - University of Pittsburgh
  • pilot program - Family Medicine, Flemington, NJ
  • moved to Grand Rapids in 1986 when daughter
    Martie matriculated at Hope College
  • Board Certified in Family Medicine and Hospice
    and Palliative Care
  • spiritual gift mercy
  • Inpatient Physician Trillium Woods - 2007-2009
  • Medical Director Hospice of Michigan Grand
    Rapids - 2010 to present

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our goals today
  • reach a better understanding of
  • how far back palliative care reaches
  • some historical landmarks along the way
  • recent history compassion pushes back against
    technology
  • palliative care today Economics 301 - the
    future of palliative care
  • meet the art of Deidre Scherer

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6
one of the ironies of life
  • By the time youre old enough to know your way
    around, youre not going anywhere.

7
Palliative Care is not exactly a new concept
  • Cure sometimes,
  • treat often,
  • comfort always.
  • Hippocrates
  • 460-357 B.C.

8
Ancient China
  • special houses death houses
  • destitute people were allowed to go there to live
    and die

9
New Zealand
  • Maoris tribe
  • family of dead person is given support in all
    possible ways
  • entire tribe joins in mourning

10
East Africa
  • Tribal elders offer spiritual and practical
    support to the dying person and their family

11
a rest along the way
  • During the Crusades in the Middle Ages,
    monasteries provided care for
  • the sick and dying
  • the hungry wayfarer
  • the woman in labor
  • the needy poor
  • the orphan
  • the leper

12
Middle Ages
  • Religious orders established hospices at key
    crossroads on the way to religious shrines
  • Santiago de Compostela (Spain)
  • Chartres (France)
  • Rome (Italy)
  • ironically, people died in these shelters while
    on pilgrimages seeking cures for their diseases

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16th 18th centuries
  • religious orders offered care of the sick and
    dying in local or regional institutions
  • but most people died at home, care for by the
    women in their families

15
17th Century
  • A young priest, St. Vincent de Paul, founded the
    holy order of Sisters of Charity in Paris, 1633
  • They, in turn, opened more than 40 houses for the
    poor, the sick, the dying
  • motto The charity of Christ impels us

16
1800s
  • Madame Garnier of Lyon, France, opened a
    calvaire to care for dying
  • 1879 Our Ladys Hospice Dublin cares only
    for the dying
  • By late 19th century, increase in municipal or
    charitably-financed infirmaries, almshouses and
    hospitals begins the medicalizing of dying

17
1900
  • Five of the Irish Sisters of Charity founded St.
    Josephs Convent, London
  • Began visiting the sick in their homes

18
1935
  • Interest grows in the psycho-social aspects of
    dying and bereavement, sparked by the work of
    Worcester, Bowlby, Lindemann, Hinton,
    Kubler-Ross, Raphael, Worden and others

19
Europe and USA
  • Up until 19th century, belief was that the family
    and church should be responsible for the dying
    person and also help loved ones cope with
    situation

20
Mid-20th century
  • The expansion of medical knowledge, fueled by
    wartime experiences, results in almost 80 of
    people dying in hospitals or a nursing home

21
1957 - 1967
  • Cicely Saunders first a social worker, then a
    nurse and finally a physician
  • Works at St. Josephs Hospice studying pain
    control in advanced cancer patients
  • Pioneered concept of opioids given by the clock
    instead of as prn pain control

22
Dame Cicely Saunders 1918-2005
  • nurse, physician, founder of St. Christophers
    Hospice, Sydenham, south London, 1967
  • No human life, now matter how wretched, should
    be denied dignity and love.

23
Dr. Cicely Saunders
  • We need to help the dying to live until they die
    and their families to live on
  • Author of three books on hospice care
  • Care of the Dying, 1960
  • The Management of Terminal Disease, 1978
  • Living with Dying, 1983

24
1967
  • Dr. Saunders opens St. Christophers Hospice in
    London
  • Emphasized multi-disciplinary approach to caring
    for dying
  • Regular use of opioids
  • Careful attention to social, spiritual and
    psychological suffering of patients and their
    families

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1974 - New Haven, Connecticut
  • Nurses carry the banner from London to America
    and begin teaching Dr. Saunders principles
  • New Haven Hospice in Branford begins caring for
    patients with cancer, A.L.S. and other fatal
    illnesses

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Canada -1975
  • Dr. Balfour Mount founds hospice and palliative
    care work in two North American hospital
    facilities
  • St. Boniface Hospital - Winnipeg
  • Royal Victoria Hospital - Montreal

29
British Columbia - 1978
  • Victoria Hospice founded as The Victoria
    Association for Care of the Dying
  • pilot program successful became Hospice
    Victoria 1982
  • began with 7 acute-care beds in Royal Jubilee
    Hospital

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1975 - 1978
  • Hospices and palliative care units open across
    USA
  • California
  • Support team at St. Lukes in NYC
  • Church Hospice Baltimore
  • Cleveland Clinic
  • Medical College of Wisconsin

32
1984
  • Congress adds Hospice Benefit

33
2009
  • Most recent financial data shows
  • 11,633 home health agencies
  • 3,533 hospices
  • Center for Medicare Medicaid Services, OSCAR
    data, April, 2011

34
2009 USA hospice care
  • USA stats
  • 1,123,495 covered patients
  • 77,822,892 covered days of care
  • 12 billion reimbursement
  • (12,085,785,062.15)
  • Source CMS OSCAR data, April, 2011

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2009 Michigan
  • 607 home health agencies
  • 104 hospices
  • 41,918 total hospice patients
  • 2,477,382 covered hospice days
  • 378,947,823.67 hospice reimbursement
  • CMS OCSAR data, April, 2011

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38
Philosophy before function
  • Palliative care (symptomatic and supportive care)
    is generally withheld until all attempts to treat
    the underlying disease and other medical problems
    are exhausted many times palliative care is
    offered with little time left for living.

39
Philosophy before function 2
  • Palliative care should be considered in
    conjunction with active treatment, and, as death
    nears, palliative care becomes more important as
    active treatment, while cure becomes less
    important

40
Philosophy before function 2
  • Palliative care should be considered in
    conjunction with active treatment, and, as death
    nears, palliative care becomes more important as
    active treatment, while cure becomes less
    important

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42
Modern definition
  • Advanced knowledge/skills to prevent and relieve
    suffering experienced by patients with
    life-limiting, life-threatening and terminal
    illnesses.
  • Expertise in assessment of patients with advanced
    disease and catastrophic injury

43
Modern definition 2
  • Coordination of interdisciplinary patient and
    family-centered care in diverse settings
  • Use of specialized care systems including
    hospice, management of the imminently dying
    patient and legal and ethical decision making in
    end-of-life care

44
Modern definition 3
  • Work with an interdisciplinary hospice or
    palliative care team to maximize quality of life
    while addressing physical, psychological, social
    and spiritual needs of both patients and family
    members thru illness, dying and bereavement

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46
Drivers of palliative care
  • Sheer demographics growth of elder population
    with diseases of senescence
  • Conventional medicine enabling younger patients
    with previously-fatal diseases to survive longer
  • Emerging infectious diseases (HIV-AIDS, hep C,
    resurgent tbc, etc.)

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48
U.S.A. Demographics I
  • over-65 age group will double between 2000 and
    2030
  • over 70 million gtage 65 by 2030
  • gtage 85 4.2 million in 2000 to 8.9 million in
    2030
  • by 2050 we will may well have 834,000 persons
    over 100 years old

49
U.S.A. Demographics II
  • we post-moderns tend to think of death as an
    option rather than a reality however
  • roughly 100 of Americans are expected to die at
    the end of their lifetimes.

50
What is Futile care?
  • use of expensive technology to prolong the
    natural dying process of terminally ill persons,
    with no realistic expectation of longer survival,
    clinical improvement or better quality of life

51
An artists rendering of futility
52
Sisyphus, by Tiziano Vecelli, 1490-1576
  • In Greek mythology, Sisyphus was doomed by
    Zeus to forever carry a huge rock uphill, only to
    have it roll back down again this went on day
    after day for eternity.

53
So How will we know.?
  • patients are often the first to know when its
    bad news
  • a sensing of body language, non-verbal
    communication, insight into ones own body and
    destiny
  • innate sense of the timing of life
  • importance of the will to live

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55
But, how will we know.?
  • consensus on futility is reached between
  • the patient
  • the family (or best friends as family
  • surrogate)
  • the spiritual advisor (pastor, priest, rabbi,
  • etc.)
  • the patients personal physician

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57
Politics of palliative care
  • Hospitals held accountable for 30-day
    re-admissions
  • DRG-type comprehensive reimbursement schemes
  • Need to reduce ER visits and un-necessary
    hospitalizations
  • Discussions of futility mandatory or simply
    essential?

58
Allen Stewart Konigsberg 1935-????
59
Woody Allen
  • Im not afraid to die. I just dont want to be
    there when it happens.

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62
History of Palliative Care Your Questions
Please
  • David L. Sharp, M.D.
  • Grand Rapids Medical Education Partners
  • Hospice of Michigan
  • 989 Spaulding SE
  • Ada, Michigan 49301
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